BP-87750Item
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Building
__ _2. Electrical
2.1 Owner Record: 3. Plumbing
�t't (i t�►�1 4. Mechanical (HVAC)
Number Phone N er
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s I- 1 2 3 - Address Total )
Contact Add 5 t
ame (print)fO
�a�itp�eesfrea, oti
Authorized ent:: -� (Please Print) `
Phone Number, as
Cont t dd es I, a � �, _
Name (Print)
to act on my behalf, in all matters relative to work author
Licerise-Number.
Construction Su fervisor/Specialty License: Signature of Owner
Licensed P
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3'T` '�� /
N me/Contractor Name: -
Estimated Cost ($) to be
o "tfie subject property hereby authorize ��. cyl f ��101
'ht is building permit application.
- "-,
Date
:. Company a
:�_i
Expiration Date:
address: ��� as 0 nerlAuthorized Agent hereby declare that the statements end information
1 Telephone:r
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knowledge and belief.
Signature: on the fore. ing application are true and accurate, to the best of my g
3.2 Ho owner Exemption - One & Two Family Only Section 11 Q.R5.1.3.1 Exception: Signed der th a ns an penalties of perjury.
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
n Homeowner performing work for which a Building' Permit is required shall be exempt from the provisions of this section; provides that if a Homeowner Date
Exception. Any
for hire to do such work, that such Homeowner shall act as supervisor. on which helshe resides or intends to reside, on which Si lure Of 0 er/Au orized Agent ,
engages a person(s)
"'s defined as follows: Person(s) who owns a parcel of land }
s of this section only, a Homeowner i farm structures: A person who constricts more thanppm
For the purposes accessory to such use and/or -
ed or detached structures N_
there is, or is intended to be, a one or two family dwelling, attach -
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one home in a two-year period shall not be considered a Homeowner.
Fee: $25.61�
Remaining Bolan
Less Ap lication
if you are applying under this section sign below:
Total Permit Fee: $
� Other $ mount $
Signature:
- _ truction total sq. ft.
_ ors
E �_ ..., . w G
- Grass Area
-- - Gross Area - Alteration to al sq. ft.
Worker's Compensation Insurance Affidavit must be completed and submitted with
this application.
lion. Failure to Svid No
affidavit will result in the denial of the issuance of the building permit Signed Permit Issued to:
- - ---
A
K
❑Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ Deck ❑ Pool ❑ Repairs
oofing/Siding ❑ Replacement window/door
❑ New Construction* ❑ Accessory Bldg. --❑ Addition No. of windows Doors_
(Energy report required) (Shed/Garage) (Energy report required) _
ITiON (s ecify)• -� �� .� +�T �-'��E'
❑ DEMOL p
Location of debris removal (per MGL C.40 Sec 54):., Dumpster on site ❑ Dumpster On Street
Facility Name:
Location:—
I, "if new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two Family: - No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit No. of Baths Unit 2
0 Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
I
0 Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other {specify):
rl HVAC (combined unit)- primary fuel, natural gas, propane, electricity, other (specify):
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II
ased Approval (R106.3.3)
AppLICATION FEW IS 501Y BE- LE � NON 'Its S
zr i
D - REG;EIVED
DARTMOUTH BUILDING DEPARTMENT �"J
400 Slocum Road
r p
_: Dartmouth, MA
02747
2 Phone: 508-910-1820 ax: 508-910-1838
www.town.dartm uth.ma.us
TO C0�9STR@9CT, REPA(R, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DIWELLING
APPLICATIONTftf;sEF3iffP�tFEr6SE QN _
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St1fLE71f�FG �PERNiIT NtJIBEE
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Buil �.
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ufer'
Zone
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Ff}L�Qf19FiNGAi0IE8-S�;.Q�f�BEf� _ -
;.:_....�;�:: ngineering- C1_Cross Y
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• t�,�tlannection
Gard
'deals Healftrornrnossion - -
= i7 oftrer _ _ �Q FNater-Cerd Sewer Eatd
Qf rte Q Gas _0 Eieetna= - -
�� GFnef _ Cat flff Cut Off }
Cuf off Cut off
L ti-Wry
-
Date:
Board of Health: Signature:
Conservation Commission: rSggnature:
Date:
,> Date: ._
l7.P.W.: Signature:
Signature:
Date:
Fire Chief: g
Dater
Other. Signature:"]
Brmef description of work being perfor e
'` cETA=IN biffiI°�Q =
C•-•-_ c y ]. - OUT F..i�.;,..
1.1 Property Address: Y-� 1.2 Assessors Map & Lot Number.
Map _ Lot
c : I V-,
Contact Person: �'t�
Phone (Number:
1.3 Historical District ❑ Yes ❑ No
�97
Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: ❑ Altering more than 25% per sidea of building
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Dispo al System Has application been submitted to the !Historic Commis 'T
0 Yes [INo Date;: